A Peruvian Psychiatric Hospital.

Excerpt

STEIN, WILLIAM W. A Peruvian Psychiatric Hospital. Lanham, MD: University Press of America, Inc. 1995. xii + 300 pp. $48.50.Stein describes himself as a “consultation anthropologist”-an ethnographic observer who engages in “the transmission of information back to hospital staff,” which “can reveal something of...the nature of such institutions...as well as the nature of their political and economic contexts” (p. 89). He holds up a mirror to hospital workers and patients. The reflection that emerges is, in his technique, a sharply drawn yet sympathetic picture of a community that wrestles with chronic mental illness.The object of Stein's study is Pavilion 20, a male charity pavilion of Hospital Victor Larco Herrera in Lima, Peru. When Stein studied it, this pavilion had 70 patients (out of 1248 for the entire hospital). These patients were cared for by 12 psychiatrists, 17 attendants, 13 nurses, 2 social workers, and 2 clinical psychologists; many of these personnel also worked in other parts of the hospital.Although Stein's gaze dwells primarily on how the denizens of Pavilion 20 see themselves and each other, he also looks at the culture and political structure of the surrounding society. He says: “The poverty of the Hospital reflected the general poverty prevailing in Peru... a circumstance that makes psychiatric practice quite a different and a much more difficult experience from comparable professional activity in a developed country” (p. 3). The psychiatrists carry out what he calls a “laminated livelihood”: they work in other hospitals and clinics, in their own private practice, on the paramedical margins as medical publishers' representatives and drug salesmen, and even outside medicine, as schoolteachers and accountants. The attendants also patch together a living, at a lower status and economic level than the doctors. Yet Stein observes that, compared with North American mental hospital attendants, his attendants were more satisfied with themselves and their work; most of them came from humble rural beginnings, but once in Lima, they belonged to the “labor elite,” with a steady income and union protection of their working conditions.Stein's picture of Pavilion 20 is broadly congruent with analyses of mental hospitals carried out by social-psychiatric investigators and reformers such as Maxwell Jones, Erving Goffman, Alfred Stanton, Daniel Levinson, Morris Schwartz, Andrew Scull, and Milton Greenblatt. To their conceptual arsenal of custodialism, total institution, and therapeutic community, Stein adds his own ingredient-“structural ambivalence.” This new concept refers to a tense duality that permeates the operational structure of mental hospitals-the dichotomy between the therapeutic, healing commitment of the institution, and the stultifying, often repressive impact of its culture on patients. The antitherapeutic features of hospital life are so intertwined with seemingly necessary routines and with material scarcity (which are, in Stein's hospital, especially strong on the charity wards) that staff take them for granted.In the United States, a professional and public focus on the shortcomings of mental hospitals led to the establishment of community mental health centers, the entry of psychiatry into general hospitals, and the substantial depopulation of mental hospitals. Stein notes that similar trends have occurred in Peru. He feels, however, that things have gone too far-that more attention must now be paid to the improvement of mental hospitals. In Peru, this will not happen, Stein believes, apart from drastic political reform, if not revolution. He ends his engaging, analytical, and even-tempered book with an uncharacteristic, almost desperate warning about “the poverty of the country (Peru), the indifference of its rulers, and the greed of those who extract its wealth” (p. 281).This is a fine book about mental health practice in institutional contexts.